16 Headache

Question 1

MC primary headaches

Answer 1

tension<br></br>migraine

Question 2

What are the pain sensitive areas of the head?

Answer 2

meninges<br></br>arteries and veins<br></br>various tissues lining cavities

Question 3

Pain mediation of headache associated iwth which CN?

Answer 3

CN

Question 4

What are the critical dx of headache,cannot miss: <br></br>CNS/neuro/vessels 3

Answer 4

SAH<br></br>carotid dissection <br></br>venous sinus thrombosis 

Question 5

What are the critical dx of headache,cannot miss: <br></br>toxins -1

Answer 5

carbon monoxide poisoning

Question 6

What are the critical dx of headache,cannot miss: <br></br>collagen vascular disease

Answer 6

temporal arteritis 

Question 7

What are the critical dx of headache,cannot miss: <br></br>Infectious disease

Answer 7

bacterial meningitis<br></br>encephalitis

Question 8

What are the EMERGENT dx of headache:<br></br>cns, neuro, vessels - 6

Answer 8

shunt failure<br></br>traction headache<br></br>tumor/mass<br></br>SDH<br></br>reversible cerebral vasocons syndrome<br></br>mountain sickness

Question 9

What are the EMERGENT dx of headache,cannot miss: <br></br>ocular/ent - 1

Answer 9

glaucoma

Question 10

What are the EMERGENT dx of headache,cannot miss: <br></br>infx disease

Answer 10

brain abscess

Question 11

What are the EMERGENT dx of headache,cannot miss: <br></br>pulmonary/o2

Answer 11

anoxic headache

Question 12

What are the EMERGENT dx of headache,cannot miss: <br></br>cv -1

Answer 12

htn crisis

Question 13

What are the EMERGENT dx of headache,cannot miss: <br></br>unsp -2

Answer 13

preeclampsia<br></br>iih

Question 14

What are the Non-emergent dx of headache:<br></br>cns/vessel/neuro - 5

Answer 14

migraine<br></br>vascular headache<br></br>trigeminal neuralgia<br></br>post trauma concussion<br></br>post lp

Question 15

What are the Non-emergent dx of headache:<br></br>occular/ent

Answer 15

sinusitis<br></br>dental<br></br>tmj

Question 16

What are the Non-emergent dx of headache:<br></br>msk

Answer 16

cervical strain<br></br>tension

Question 17

What are the Non-emergent dx of headache:<br></br>allergy

Answer 17

cluster or hist headache

Question 18

What are the Non-emergent dx of headache:<br></br>infx

Answer 18

febrile headache non neuro source

Question 19

What are the Non-emergent dx of headache:<br></br>cv

Answer 19

htn (rare)

Question 20

What are the Non-emergent dx of headache:<br></br>unsp

Answer 20

effort dep/coital<br></br>med overuse/rebound

Question 21

<span>A rapid and severe onset of pain (“thunderclap”) has been associated with serious causes of headache. Thunderclap headache alone cannot indicate if there is a serious underlying cause of headache, such as SAH, but is used in conjunction with other signs and symptoms</span>

Question 22

<span>Almost all studies dealing with subarachnoid bleeding report that patients move from the pain-free state to severe pain within seconds to minutes. </span>

Question 23

<span>If the patient with moderate or severe headache can indicate the precise activity in which he or she was engaging at the time of the onset of the headache, the suddenness of onset warrants consideration of SA</span>

Question 24

<span>Headaches that come on during exertion raise concern for vascular events.</span>

Question 25

If there is a history of head trauma , the differential diagnosis shifts markedly toward epidural and subdural hematoma, traumatic SAH or intraparenchymal hemorrhage, skull fracture and closed head injuries, such as concussion and diffuse axonal injury.

Question 26

Unilateral pain is more suggestive of migraine or localized inflammatory process in the skull (e.g., sinus) or soft tissue

Question 27

Temporal arteritis, temporomandibular joint (TMJ) disease, dental infections, and sinus infections frequently have a highly localized area of discomfort.

Question 28

Meningitis, encephalitis, SAH, and even severe migraine, although intense in nature, are usually more diffuse in their localization.

Question 29

atients whose headaches rapidly improve when they are removed from their environment or recur each time they are exposed to a particular environment (e.g., basement workshop) may have carbon monoxide poisoning. 

Question 30

Migraine headaches, increased intracranial pressure, temporal arteritis, and glaucoma can all manifest with severe nausea and vomiting, as can some systemic viral infections with headache.

Question 31

Immunocompromised patients are at risk for unusual infectious causes of headache, which may present with deceptively low-grade symptomatology. Toxoplasmosis, cryptococcal meningitis, and abscess are very rare but may be seen in patients with a history of human immunodeficiency virus (HIV) or other immunocompromised state. 

Question 32

Another special population to consider is the pregnant and peripartum woman. In addition to the typical causes of secondary headache, this population may have headache resulting from preeclampsia, and is more likely to have headache caused by idiopathic IIH and reversible cerebral vascular syndrome.

Question 33

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Question 35

deficits of extraocular movements localizing to cranial nerves (CNs) III, IV, and VI, or papilledema noted on CN II assessment, may indicate the presence of increased intracranial pressure due to a mass lesion or IIH

Question 36

when headache is associated with an acutely red eye, consideration of acute angle closure glaucoma should prompt testing of intraocular pressure.

Question 37

Signs of meningeal irritation (nuchal rigidity, jolt accentuation, or Kernig and Brudzinski signs) are concerning for SAH or meningitis. Any focal neurological deficit found on examination, regardless of subtlety, warrants further investigation. 

Question 38

Nausea and vomiting are often associated with migraine, but they are also associated with intracranial mass, acute angle closure glaucoma, intracranial bleeding, and carbon monoxide poisoning.

Question 39

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Question 46

LP with measurement of the opening pressure and cerebrospinal fluid (CSF) analysis is indicated when assessing for an infectious process, IIH, or SAH. 

Question 47

Question 48

Ottawa Subarachnoid Hemorrhage Rule

• Inclusion: patients age 15 and over, nontraumatic headache, peak intensity within 1 h of onset
• Exclusion: New neurological deficits, prior aneurysm, prior SAH, known intracranial mass, chronic recurrent headaches
• If none of the following are present, SAH can be reasonably ruled out:
  • a. 
    Age >40 years
  • b. 
    Neck pain or stiffness
  • c. 
    Witnessed loss of consciousness
  • d. 
    Headache onset during exertion
  • e. 
    Thunderclap headache (immediate peak pain)
  • f. 
    Limited neck flexion

Question 49

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Question 51

Question 52

Question 53

Primary headaches that are severe or not responsive to NSAIDS can be treated with parenteral nonnarcotic medications.
Recommended options include three classes of medication:
1)intravenous (IV) antiemetic dopamine antagonists, such as metoclopramide (10 mg) or prochlorperazine (10 mg);
2)subcutaneous (SC) migraine-specific agents, such as Sumatriptan (6 mg); and
3)an intramuscular (IM) or IV NSAID, such as Ketorolac (15 mg).